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Second stage with cartilage graft, superficial temporal fascial flap, and scalp split thickness skin grafts (STSG). (A) Elevation of the framework exposing the cartilage. (B) The piece of cartilage banked under the thoracic skin is fixed to the base. (C) Creation of the posterior wall of the concha. (D) The superficial temporal fascial flap is rotated downward. (E) 1-Year postoperative result with scalp STSG and temporal parietal fascia (TPF). (F) 1-Year postoperative result.
Source publication
Sculpting a tridimensional autologous rib cartilage framework is essential to restore a natural ear shape and becomes routine with preoperative training, but management of the skin is the key to minimizing complications. Here the authors provide a classification scheme to manage auricular skin: Type 1 is a Z-plasty with transposition of the lobule;...
Context in source publication
Context 1
... and to add them during the second stage. Although sculpting may seem a daunting task, we actually believe that the biggest challenge for a surgeon interested in ear reconstruction is learning to best use the skin remnants. The main goal is to plan a skin approach that covers the framework with vascularized tension-free cutaneous flaps. We devised an algorithm to manage the skin remnants, based on a three-stage classification. This surgical classification does not depend on the shape of the fibrocartilaginous remnants, but instead on the skin potential. Type 1 is a Z-plasty with transposition of the lobule. Type 2 is a transfixion incision of the microtic ear. Type 3 exposes the cartilage remnants through a cutaneous incision (Table 3). An identical skin approach can be selected for microtia with very different shapes but similar skin potential (Fig. 6). Observing the shape of the skin remnants is not suffi- cient to choose the most appropriate type of skin approach. It can only be done after drawing the ideal position of the ear on the abnormal side. The distances (root of the helix to orbit and lobule to oral commissure) and the angle (axis of the ear–nasal dorsum) serve as landmarks to place the future ear (Fig. 7). These land- marks from the normal side are drawn on the abnormal side and remain visible during surgery. In craniofacial microsomia, due to the asymmetry of the face, these distances cannot always be respected. It is possible to accept a compromise in the anteroposterior plane because the two profiles are never seen at the same time. It remains essential, however, to avoid any compromise in the vertical plane; this would result in visible asymmetry from the frontal view. Once the ideal position of the new ear has been determined and drawn on the skin, one must look at the position of the lobule. If the lobule is perfectly positioned and broad, one may use a type 1 (Z-plasty with transposition of the lobule) approach. In our practice, this is a very rare situation. If the lobule is narrow, we prefer to use a type 2 (the transfixion incision will then be very low) or a type 3b. In type 2, we must appreciate the ideal level of the transfixion skin incision. This level can be precisely located by pulling the remnants posteriorly and marking the point where they reach the drawing of the contour of the ear. This will mark the level of the transfixion incision and back cut. If the dimensions of the abnormal ear are approximately those of the normal ear, we can use a type 3a, in a single stage. If the upper pole is too small, we can use a type 2 (the transfixion incision will then be high) and perform the reconstruction in two stages. We prefer type 2 or 3 to type 1, which puts the tip of the posterior flap at risk for skin necrosis. Furthermore, it can be used only if the insertion of the lobule is in its ideal position. Type 3a requires the upper part of the ear to be large enough to fit in the framework, which is an infrequent situation. Overall, type 2 and type 3b approaches are most common. The retroauricular sulcus is created during the second stage, which is performed at least 6 months after the first. Depending upon the degree of projection required, we will choose alternatively between the following techniques. When a small amount of projection is needed, the periphery of the ear is incised and the framework is elevated, preserving a layer of soft tissue covering the cartilage. The retroauricular skin is then advanced to the level of the sulcus, anticipating the formation of a dog ear by a triangular skin excision. The soft tissue covering the posterior surface of the base is skin grafted. Instead of full thickness skin grafts taken from the groin or from the inner side of the upper arm, we prefer to use split thickness skin grafts (STSG) from the scalp as advocated by Satoru Nagata, which, in our experience, have an excellent color match and do not retract if placed on a well-vascularized bed. The caudal portion of the retroauricular skin creates a non-hair-bearing flap, but the cranial skin flap brings hair into the sulcus. Therefore, we cover the upper portion of the retroauricular area with a separate skin graft. When it is necessary to add moderate projection to the framework to match the contralateral ear, after elevation of the ear following Brent’s technique, we create a tunnel behind the framework to bury a piece of cartilage under the retroauricular soft tissue. This tunnel can be dissected behind the antihelix to achieve maximal projection of the upper portion of the ear or behind the antitragus to project the lobule, or occasionally behind both. When, to match the contralateral ear, it becomes necessary to reconstruct the entire posterior wall of the concha, we use a modification of Nagata’s technique. 6 Like him, we add a piece of cartilage behind the base and cover it by a superficial temporal fascial flap. The flap is then skin grafted (STSG harvested from the scalp) (Fig. 8). Nagata described raising the framework along with a layer of soft tissue. We prefer to expose the posterior surface of the base. Doing so, we can mobilize the entire base all the way to the level of the concha, which provides more space to place the additional piece of cartilage (banked under the thoracic skin during the first stage). This piece is sculpted to reproduce the posterior wall of the concha. This thin curved piece is secured directly to the posterior surface of the framework, behind the antihelix, providing stability to the reconstructed posterior wall of the concha. This modification of Nagata’s technique has several advantages: (1) the framework can be mobilized extensively and some adjustments to the axis or the position of the reconstructed ear are made possible, (2) direct coverage of the posterior surface of the framework without inter- position of soft tissue results in a thinner ear as seen from behind, and (3) removal of wire sutures and thinning of the posterior edge of the framework can be done if necessary. The modified Nagata technique is the one used most frequently in our practice. Ear reconstruction is a challenging surgery, but with training and method, results can become excellent and reproducible. 7–11 Sculpting autologous rib cartilage, often thought to be a daunting task, becomes the most-routine part of the procedure. Appropriate use of the auricular skin is in fact the challenge, and mastering this step is the real key to good results and few complications. We hope that the classifications provided here will help surgeons interested in ear reconstruction to choose the optimal skin approach and ultimately provide their patients with a normal-looking ear for the rest of their ...
Citations
... The retroauricular groove is not reconstructed, and hence the ear is entirely connected to the head. In the second surgery, the retroauricular groove is reconstructed to project the ear and achieve a natural appearance [28]. ...
Background
Microtia is a congenital malformation of the auricle that affects approximately 4 of every 10,000 live newborns. Radiographic film paper is traditionally employed to bidimensionally trace the structures of the contralateral healthy ear in a quasi-artistic manner. Anatomical points provide linear and angular measurements. However, this technique proves time-consuming, subjectivity-rich, and greatly dependent on surgeon expertise. Hence, it’s susceptible to shape errors and misplacement.
Methods
We present an innovative clinical workflow that combines 3D printing and augmented reality (AR) to increase objectivity and reproducibility of these procedures. Specifically, we introduce patient-specific 3D cutting templates and remodeling molds to carve and construct the cartilaginous framework that will conform the new ear. Moreover, we developed an in-house AR application compatible with any commercial Android tablet. It precisely guides the positioning of the new ear during surgery, ensuring symmetrical alignment with the healthy one and avoiding time-consuming intraoperative linear or angular measurements. Our solution was evaluated in one case, first with controlled experiments in a simulation scenario and finally during surgery.
Results
Overall, the ears placed in the simulation scenario had a mean absolute deviation of 2.2 ± 1.7 mm with respect to the reference plan. During the surgical intervention, the reconstructed ear was 3.1 mm longer and 1.3 mm wider with respect to the ideal plan and had a positioning error of 2.7 ± 2.4 mm relative to the contralateral side. Note that in this case, additional morphometric variations were induced from inflammation and other issues intended to be addressed in a subsequent stage of surgery, which are independent of our proposed solution.
Conclusions
In this work we propose an innovative workflow that combines 3D printing and AR to improve ear reconstruction and positioning in microtia correction procedures. Our implementation in the surgical workflow showed good accuracy, empowering surgeons to attain consistent and objective outcomes.
... The number of stages refers to the number of operations needed to reach the final outcome. The classification and management of skin samples for the rib cartilage are key steps during sculpting and finalizing the product [119,120]. Autologous reconstruction methods are highly durable with low infection rates, but may need multiple operations and are accompanied by pain. ...
Current 3D scanning and printing technologies offer not only state-of-the-art developments in the field of medical imaging and bio-engineering, but also cost and time effective solutions for surgical reconstruction procedures. Besides tissue engineering, where living cells are used, bio-compatible polymers or synthetic resin can be applied. The combination of 3D handheld scanning devices or volumetric imaging, (open-source) image processing packages, and 3D printers form a complete workflow chain that is capable of effective rapid prototyping of outer ear replicas. This paper reviews current possibilities and latest use cases for 3D-scanning, data processing and printing of outer ear replicas with a focus on low-cost solutions for rehabilitation engineering.
... The technique of microtia reconstruction has developed over the years with Tanzer [4] using autologous costal cartilage for total auricular reconstruction, followed by the progressing efforts to improve the technique by Brent [5], Nagata [6,7], then Firmin and Marchac [8,9]. ...
... The aesthetic outcome shows good shape, position, and similarity of the frameworks of the reconstructed ears, with a decrease in the percentage of difference between both sides Figs. (8,9). There was a decrease in the number of surgical stages without an increase in the rate of complications or donor site morbidity. ...
... All procedures were performed under general anesthesia, while the patient was supine with the head tilted to the deformed side. All patients underwent two-stage reconstructive surgery using the modified Firmin technique, [22][23][24] with some special modifications to adapt the anatomical features of grade IIB Tanzer constricted ear. ...
Unlabelled:
Group IIB constricted ear is described as a deformity of helix, antihelix, and scapha (deficient upper third of ear). The length of the ear is markedly shortened, and the skin cover is insufficient to cover the cartilaginous framework after refashioning. The current study described certain modifications to the known autologous auricular reconstruction technique to adapt specific anatomical features of severe group IIB Tanzer constricted ear and reviewed the postoperative surgical outcomes and complications. It also evaluates the postoperative patient satisfaction.
Methods:
A prospective study includes 20 patients who underwent modified autologous reconstruction using costal cartilage for unilateral severe grade IIB constricted ears in the period between October 2018 and November 2021. Mean follow-up period was 6 months. Satisfaction was recorded using a questionnaire form 4 months after second-stage surgery.
Results:
Patients reported excellent (n = 14) and good (n = 7) results. According to a four-point Likert scale, the average aesthetic outcome score was 3.8. No complications were recorded, except in one patient who shows postoperative collection. The helix, concha, and lobule were the most satisfying parts to patients. The least pleasing subunit to patients was the antihelix. All patients were satisfied with the elevation of the auricle. They reported symmetry in size, shape, and position in 14 of 20 (70%) patients.
Conclusions:
Modified autogenous auricular reconstruction is useful in correcting severe group IIB Tanzer constricted ear deformities. Because it addresses all the anatomical features of this deformity, this technique is reproducible and reliable and has offered consistently effective results.
... This was later by Nagata and Firmin. [9][10][11][12][13][14] The method developed by Nagata can only correct the upper helical area of a constricted ear. The extreme variety of post-traumatic defects and deformities does not allow us to offer universal methods of surgery. ...
Traumatic ear amputation and post-traumatic nose defect are aesthetic deformities that can have negative consequences (lead to psychological trauma), leading to a change in the quality of life. The presented clinical case describes a protocol for the reconstruction of a partially amputated defect of the external ear and nose, which required various surgical steps; including the removal of cartilage from the ribs, followed by the creation of a cartilaginous model of the ear, the introduction of its subcutaneous region behind the ear, taking into account the anatomy of the outer ear as much as possible. The second stage after 1.5 months is the restoration of the amputated ear area with a combined superficial temporal fascial flap, costal cartilage with suturing to the amputated part of the ear and dorsal rhinoplasty using modeling costal autocartilaginous flap. The postoperative result is satisfactory with the restoration of a good aesthetic appearance of the ear and nose. Reconstruction of the external ear after partial traumatic amputation and post-traumatic nose defect with autocartilage from the ribs provides a stable aesthetic result and becomes the method of choice for such injuries.
... External ear anomalies describe a wide range of birth defects such as microtia and anotia, as well as amputation and burns that can result from animal bites, surgery and sometimes cancer (1). Different clinical approaches are used to correct such anomalies and one of the most used is a 2-step method, consisting of harvesting autologous cartilage from ribs and carving it in the shape of the ear before autologous implantation (2). However, this technique possesses some disadvantages such as donor-site morbidity and poor elasticity of the cartilage. ...
Background and objectives:
Ear cartilage malformations are commonly encountered problems in reconstructive surgery, since cartilage has low self-regenerating capacity. Malformations that impose psychological and social burden on one's life are currently treated using ear prosthesis, synthetic implants or autologous flaps from rib cartilage. These approaches are challenging because not only they request high surgical expertise, but also they lack flexibility and induce severe donor-site morbidity. Through the last decade, tissue engineering gained attention where it aims at regenerating human tissues or organs in order to restore normal functions. This technique consists of three main elements, cells, growth factors, and above all, a scaffold that supports cells and guides their behavior. Several studies have investigated different scaffolds prepared from both synthetic or natural materials and their effects on cellular differentiation and behavior.
Methods and results:
In this study, we investigated a natural scaffold (alginate) as tridimensional hydrogel seeded with progenitors from different origins such as bone marrow, perichondrium and dental pulp. In contact with the scaffold, these cells remained viable and were able to differentiate into chondrocytes when cultured in vitro. Quantitative and qualitative results show the presence of different chondrogenic markers as well as elastic ones for the purpose of ear cartilage, upon different culture conditions.
Conclusions:
We confirmed that auricular perichondrial cells outperform other cells to produce chondrogenic tissue in normal oxygen levels and we report for the first time the effect of hypoxia on these cells. Our results provide updates for cartilage engineering for future clinical applications.
... [17][18][19] However, autologous costal cartilage has remained the most widely used material in ear reconstruction worldwide and is considered by most surgeons as the best long-term option. [20][21][22] A survey of the surgeons attending the fourth International Ear Reconstruction Congress in Edinburgh revealed that 93.5% use autologous cartilage as opposed to 6.5% who use an artificial framework. 1 Comparably, a national survey of the American Society of Plastic Surgeons in 2013 showed that 8% of plastic surgeons prefer using porous polyethylene for microtia reconstruction and only 1.6% prefer osseointegrated prostheses. ...
Background: The initial step in setting up standardized microtia-atresia service is investigating the current status of the service and comparing this to internationally recognized guidelines or care standards. In many countries, documented information about micro-tia care is lacking. This study is an initiative to guide reform efforts of national microtia service in any country. The UK care standards for microtia-atresia can be a useful model to help set up a comprehensive microtia-atresia service. Methods: The authors conducted a survey to investigate different aspects of microtia service in Egypt. The major plastic surgery centers (n ¼ 22) were surveyed by a structured questionnaire. The results were compared with the UK care standards for microtia-atresia to identify the aspects that need improvement. Thorough analysis of the main problems in microtia-atresia service is presented. Results: The authors found that microtia service is fragmented between the surveyed centers with 65% of the centers treating less than 10 microtia cases annually. Multiple surgeons are responsible for ear reconstruction in 90% of centers and only 25% of them practise a multidisciplinary team approach. None of the centers uses validated tools of aesthetic or psychological patient-reported outcome measures. Recommendations: These 5 recommendations are the keys to reforming microtia service in any country: (1) Establishing nationally designated centers to concentrate the required expertise. (2) Assigning fewer high-volume surgeons to optimize the surgical outcomes. (3) Providing treatment by experienced multidisciplinary teams. (4) Using validated tools of patient-reported outcome measures. (5) Collecting and keeping standardized records for regular audit and intercenter studies.
... Nagata and Firmin described a 2-stage autologous approach that imparts greater detail but necessitates larger cartilage volumes. Reconstruction using Nagata and Firmin techniques is typically offered at later ages when the child had a chest circumference of at least 60 cm, the standard indicator of sufficient rib stock (48)(49)(50)(51)(52). ...
... Françoise Firmin went on to describe what many consider a modified-Nagata technique, characterized by projection pieces of the framework and a formal classification of skin approaches which she calls Type 1, 2, 3a and 3b. This technique provides a standardized approach to auricular reconstruction which takes into account the microtia remnant and missing contours to be reproduced (51,52). These techniques use autologous costal cartilage to reconstruct the ear in 2 stages (48-51, 60-61). ...
Objectives
To present recommendations for the coordinated evaluation and management of the hearing and reconstructive needs of patients with microtia and aural atresia.
Methods
A national working group of 9 experts on microtia and atresia evaluated a working document on the evaluation and treatment of patients. Treatment options for auricular reconstruction and hearing habilitation were reviewed and integrated into a coordinated care timeline.
Results
Recommendations were created for children with microtia and atresia, including diagnostic considerations, surgical and non-surgical options for hearing management and auricular reconstruction, and the treatment timeline for each option. These recommendations are based on the collective opinion of the group and are intended for otolaryngologists, audiologists, plastic surgeons, anaplastologists, and any provider caring for a patient with microtia and ear canal atresia. Close communication between atresia/hearing reconstruction surgeon and microtia repair surgeon is strongly recommended.
... This ''W'' flap embraces the terminal portion of the framework, continuing to the helix, allowing the posterior lobule skin to be incorporated into the mastoid skin flap. 10,12 As the patient displays more native anatomical structures that can be incorporated into the cartilage framework during the reconstruction process, it becomes a mixture of the patient's anatomical elements and of the costal cartilage framework. Nagata created the ''conchal'' and ''small conchae'' groups that basically differ in the amount of anatomical structures that can be incorporated into the cartilage framework. ...
... The length of skin incisions varies accordingly following a more vertical direction as more cartilage is left in place during reconstruction. [10][11][12] As each group is formed by a specific anatomical malformation, this classification presents a direct relationship between the clinical manifestation of microtia and the technical requirements during surgery for their correction, but has the disadvantage that it lacks a progression from the least important alteration to the largest, causing confusion in those surgeons that are not familiarized with this topic. ...
... 3 Most of the reconstruction, if not all of it, can be accomplished in 2 stages with only minor revisions required beyond these 2 operations. 3,[8][9][10][11][12][13] Optimal reconstruction requires costal cartilage of sufficient size and shape to carve the key framework details and maintain the strength to display these details through the overlying skin envelope. Best results can be obtained when reconstruction begins at age 9 to 10 years or older, as cartilage width and length provide the optimal raw material for reconstruction. ...
Measurements from a certain population may show a similar pattern that allows an alteration to be easily recognized and enable a better surgical approach. In our population, the changes in the anthropometric measurements of the lips are unknown, so our objective is to determine the variations in these measurements by decades of age to achieve a better aesthetic and reconstructive surgical approach. Anthropometric measurements of the lips were taken with a vernier in relation to the previously marked anatomical points. The sample consists of 174 patients who came for care not related to labial pathologies with ages between 20 and 80 years with Mexican nationality. We use the sample calculation formula to estimate an average, with an alpha error of 0.5 and a tolerance of 2 mm of the data for the measurements of the height of the lower face with an average measurement of 56.2 mm and a SD of 8.87 mm of the Marzena's article. Wyganowska-Świątkowska and colleagues Average measurements were obtained, where a progressive longitudinal increase in measures: al-ch, sbl-cph, sn-Is, li-sto, cph-Is, li-sl, ch-li, li-pg according to aging is confirmed. In contrast, the ch-cph and ch-sbl measures, remain the same despite the aging, showing greater changes in the sagittal plane than in the parasagittal. The study only shows measures of length, so caring out a magnetic resonance imaging study to also measure the volume and perform it with a larger sample to have the optimal standard is further needed.
... Different objects were printed to evaluate and compare the printability and resolution of the HA-TYR microgel bioinks ( figure 3(D)). Conical tubes, two-layered grid structures, and ear shapes [31] were printed with the HA-TYR bioinks with mesh aperture diameters of 40, 100 and 500 µm. Although all structures were printed with good shape recovery, a clear difference in the printing precision was noticed. ...
3D bioprinting offers an excellent opportunity to provide tissue-engineered cartilage to microtia patients. However, hydrogel-based bioinks are hindered by their dense and cell-restrictive environment, impairing tissue development and ultimately leading to mechanical failure of large scaffolds in vivo. Granular hydrogels, made of annealed microgels, offer a superior alternative to conventional bioinks, with their improved porosity and modularity. We have evaluated the ability of enzymatically crosslinked hyaluronic acid (HA) microgel bioinks to form mature cartilage in vivo. Microgel bioinks were formed by mechanically sizing bulk HA-tyramine hydrogels through meshes with aperture diameters of 40, 100 or 500 µm. Annealing of the microgels was achieved by crosslinking residual tyramines. Secondary crosslinked scaffolds were stable in solution and showed tunable porosity from 9% to 21%. Bioinks showed excellent rheological properties and were used to print different objects. Printing precision was found to be directly correlated to microgel size. As a proof of concept, freeform reversible embedding of suspended hydrogels printing with gelation triggered directly in the bath was performed to demonstrate the versatility of the method. The granular hydrogels support the homogeneous development of mature cartilage-like tissues in vitro with mechanical stiffening up to 200 kPa after 63 d. After 6 weeks of in vivo implantation, small-diameter microgels formed stable constructs with low immunogenicity and continuous tissue maturation. Conversely, increasing the microgel size resulted in increased inflammatory response, with limited stability in vivo. This study reports the development of new microgel bioinks for cartilage tissue biofabrication and offers insights into the foreign body reaction towards porous scaffolds implantation.
