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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 2  |  Page : 490-496

Assessment of limited stage reconstruction of auricular deformities using autogenous costal cartilage


1 Department of Otorhinolaryngology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Plastic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission23-Sep-2013
Date of Acceptance26-Jan-2014
Date of Web Publication26-Sep-2014

Correspondence Address:
Tarek Abd Elrahman Abd Elhafez
MBBCh, MSc, Otorhinolaryngology Department, Faculty of Medicine, Menoufia University, Menoufia 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.141735

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  Abstract 

Objective
To evaluate the results of ear reconstructions in cases of auricular dysplasia utilizing autogenous costal cartilage graft, using two-stage versus three-stage technique of auricular reconstruction.
Background
Total reconstruction of the absent auricle because of congenital microtia is a complex topic that can be carried out either by alloplastic material or by autogenous material such as costal cartilage.
Patients and methods
This prospective study evaluated 22 patients with auricular deformities who were presented to ENT and Plastic Surgery Departments. Patients are assessed preoperatively by history, general and local examination. Esthetic assessment, photo documentation, audiological and radiologic evaluation were carried out. The patients were divided into two groups according to the stages of reconstruction: two-stage (using temporalis fascia and skin graft) and three-stage (using tissue expander) reconstruction. Patients were assessed postoperatively according to doctor and patient satisfaction. The latter was measured by Glasgow benefit inventory questionnaire.
Results
The surgical outcome was good to fair for the majority of the patients in terms of size, texture and shape of the ear, according to doctor satisfaction, with no significant difference between the two techniques (P > 0.05). Regarding patient satisfaction, there were no significant differences between both the techniques (P > 0.05). There was a significant difference between the two techniques regarding postoperative skin texture and the rate of development of postoperative complications in favor of group II, using tissue expander (P = 0.002).
Conclusion
The microtic ear can be satisfactorily reconstructed using autogenous costal cartilage graft either by two-stage technique (using temporalis fascia flap and skin graft) or three-stage technique (using tissue expander), with no significant difference between the two techniques regarding doctor and patient satisfaction.

Keywords: Auricular deformities, auricular reconstruction, costal cartilage graft, microtia, otoplasty


How to cite this article:
El-Rashidy AL, Gharib F, Ragab A, Abd Elhafez TA. Assessment of limited stage reconstruction of auricular deformities using autogenous costal cartilage. Menoufia Med J 2014;27:490-6

How to cite this URL:
El-Rashidy AL, Gharib F, Ragab A, Abd Elhafez TA. Assessment of limited stage reconstruction of auricular deformities using autogenous costal cartilage. Menoufia Med J [serial online] 2014 [cited 2019 Nov 21];27:490-6. Available from: http://www.mmj.eg.net/text.asp?2014/27/2/490/141735


  Introduction Top


Auricular losses are either partial or total and may be congenital or traumatic deformities [1]. To construct an almost normal ear is an open challenge to any surgeon. The auricular reconstruction can be performed either by alloplastic material or by autogenous material such as costal cartilage [2].

Congenital defects of the outer ear, including the external auditory meatus and the auricle, and the middle ear often occur together, requiring cosmetic treatment and rehabilitation of hearing to be addressed simultaneously. Both tasks are challenging for surgeons. Reconstruction of the auricle is a particularly demanding procedure, as the auricle is a very difficult form to imitate. Moreover, rehabilitation of hearing depends on the individual's condition and the surgeon's technique; the outcome is dependent upon seamlessly conjoining two operations [3].

The aim of the study was to evaluate the results of ear reconstructions in cases of auricular dysplasia utilizing autogenous costal cartilage graft, using two-stage (temporalis fascia and skin graft) versus three-stage (tissue expander) technique for auricular reconstruction.


  Patients and methods Top


Our study was a prospective study on 22 patients with auricular deformities who were presented to the ENT and Plastic Surgery Departments in Menoufia University Hospital from August 2007 to January 2012. The patients submitted a written consent according to the ethical committee of the hospital.

Preoperative assessment

All patients were evaluated by history taking and general examination. Local examination of the ear was conducted including laterality (all cases in the present study were unilateral), type of deformity, condition of nearby skin, the presence or absence of external auditory canal atresia, and shape and dimensions of the normal ear. Esthetic assessment of the ear was performed including height, width, axis, auricular projection, and protrusion. This was followed by photo documentation in anterior, posterior, oblique (bilaterally), lateral (bilaterally), and close-up views. Audiological evaluation included pure tone audiometry or auditory brainstem response according to the age of patient. Radiologic evaluation with computed tomographic scan of temporal bones was carried out to assess the external auditory canal, middle and inner ear.

All patients had lobular-type microtia according to Nagata classification [Table 1] [4] or dysplasia grade 3 according to Weerda classification [5]. Patients were classified into two groups: group I (10 patients) was operated upon using temporalis fascia flap and skin graft, and group II (12 patients) was operated upon after implantation of tissue expander without using temporalis fascia flap or skin graft.
Table 1: Nagata classification of ear deformities [4]

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Operative technique

Template preparation

First, we prepared the print of the normal ear on the radiograph using a marker or the template may be previously prepared using the same material of hearing aid template (silicone) [Figure 1].
Figure 1:

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Group I

First stage: auricular framework reconstruction

  1. Autogenous rib cartilage harvest and framework fabrication: We harvested the ipsilateral costal cartilage with regard to the site of deformity to localize the postoperative pain to one side of the body so that the patient can sleep on the other side. The sixth, seventh, and eighth costal cartilages were harvested en bloc [Figure 2].
  2. Implantation of the cartilaginous framework and its covering by the fascia flap and skin grafting [Figure 3].
Figure 2:

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Figure 3:

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We needed two incisions for obtaining the fascia flap: the first was 3-4 mm from the hair-bearing skin, and the second was 4-5 cm behind the hairline. The anterior and posterior scalp flaps were elevated in the subcutaneous plane immediately deep to the hair follicles. Then a postauricular fascia flap measuring about 7 × 5 cm was prepared and wrapped. The flap was based on the posterior auricular muscle. The fascia flap was designed so that it could cover the margin of the cartilage framework totally and without injury to the blood vessels and nerves. To cover the helix of the framework, a postauricular skin flap measuring ~8 cm in length and 5 cm in width proved to be sufficient.

Second stage: tragal reconstruction

The tragus was constructed by a transverse flap from the conchal area, which was doubled on itself by adding cartilage strut for support taken from the contralateral concha.

Group II

First stage: tissue expander implantation

  1. An ~3 cm incision was made in the scalp, 3-5 mm from the temporal hairline. The dissection was performed at the sub facial level till reaching below the rudimentary auricle, and a pocket was created in the mastoid area. The skin flap in the scalp was thicker than that in the hairless area.
  2. After careful hemostasis, the 50 ml kidney-shaped expander was inserted into the subcutaneous pocket. The valve was placed beneath the skin or left outside (to be easy for injection by the patient).
  3. Inflation was usually started 10 days after implantation, and was made three times a week, using 3 ml normal saline solution injection each time (the patient or his father was trained to inject). It usually took 2 months for the tissue expander to be injected to the 55-60 ml size.
  4. About 1 month after the last inflation, we obtained non-hair-bearing, thin and well-vascularized expanded skin in the mastoid area [Figure 4].
Figure 4:

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Second stage: auricular reconstruction using autogenous costal cartilage graft

About 3 months after tissue expander implantation, ear reconstruction was performed:

  1. Lobule transposition: The superior part of the lobule vestige was rotated posteriorly and inferiorly to reconstruct the infrastructure of the auricle. This was performed through anterior incision.
  2. Expander removal: C-shaped incision was made 3-5 mm from the temporal hairline. The expander was removed.
  3. Autogenous rib cartilage harvest and framework fabrication: We harvested the sixth, seventh, and eighth costal cartilages individually in children.


To acquire a three-dimensional contour, the framework was fabricated and was composed of three levels, with each level representing different elevation [Figure 5].
Figure 5:

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Third stage: construction of a pseudomeatus and formation of tragus

Similar to group I.

Postoperative assessment

Patients are assessed according to doctor and patient satisfaction:

  1. Doctor satisfaction: It is scored according to size of the auricle, position of the auricle, accuracy of the auricular details, skin condition, presence of complications on the donor sites (chest and thigh) for the presence of keloids, or other complications [Table 2].
  2. Patient satisfaction: It is measured by the Glasgow benefit inventory questionnaire (GBI) [Table 3] [6]. The results were interpreted as:
Table 2: Doctor satisfaction scoring system

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Table 3: The Glasgow benefit inventory questionnaire (all-purpose) [6]

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Total score

  1. Sum all the responses (questionnaire 1-18)
  2. Divide by 18 (to obtain an average response score)
  3. Subtract 3 from the average response score
  4. Multiply by 50.


General subscale score

  1. Sum 12 of the responses (questionnaire 1, 2, 3, 4, 5, 6, 9, 10, 14, 16, 17, and 18)
  2. Divide by 12 (to obtain an average response score)
  3. Subtract 3 from the average response score
  4. Multiply by 50.


Social support score

  1. Sum 3 of the responses (questionnaire 7, 11, and 15)
  2. Divide by 3 (to obtain an average response score)
  3. Subtract 3 from the average response score
  4. Multiply by 50.


Physical health score

  1. Sum 3 of the responses (questionnaire 8, 12, and 13)
  2. Divide by 3 (to obtain an average response score)
  3. Subtract 1 from the average response score
  4. Multiply by 25.



  Results Top


This study was carried out in Menoufia University Hospitals on 22 patients, eight men and 14 women, and the mean (±SD) age was 13.5 ± 6.19 years, ranging from 5 to 22 years. Of them, eight patients (36.40%) had positive consanguinity of the parents, and six patients (27.30%) had family history of congenital anomalies. In our study, all cases were congenital [Table 4].
Table 4: Medical history of the studied group

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Group I

Three patients (30%) had good outcome, four patients (40%) had fair outcome and three patients (30%) had poor outcome, according to doctor satisfaction [Table 5]. On the contrary, and according to the GBI questionnaire for patient satisfaction, the mean total score was 35.5, the mean general subscale score was 36.64, the mean social support score was 29.96 and the mean physical health score was 36.62 [Table 6].
Table 5: Doctor satisfaction postoperatively

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Table 6: Patient satisfaction according to Glasgow benefit inventory, measuring the changes in the quality of life

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Four patients (40%) had normal skin texture, whereas six patients (60%) had abnormal skin texture postoperatively [Table 7]. Two patients (20%) had postoperative sloughing of skin, two patients (20%) had postoperative wound infection and two patients (20%) had donor-site morbidity [Table 8] and [Table 9].
Table 7: Relationship between the operation type and the skin texture of the ear

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Table 8: Relationship between the operation type and complications

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{Table 9}

Group II

Four patients (33.3%) had good outcome, six patients (50%) had fair outcome and two patients (16.6%) had poor outcome, according to doctor satisfaction [Table 5]. On the contrary, and according to the GBI questionnaire for patient satisfaction, the mean total score was 37.43, the mean general subscale score was 38.15, the mean social support score was 33.30 and the mean physical health score was 47.20 [Table 6].

All patients had normal skin texture postoperatively [Table 7]. No patients had postoperative complications [Table 8].


  Discussion Top


The partial or total absence of one or both external ears (whether a congenital anomaly or the result of trauma) poses difficult problems. For the plastic surgeon, the construction of an ear constitutes one of the most challenging surgical procedures. In addition, it demands multiple procedures, with the attendant risks of complications such as infection, errors in design, shrinking or distortion of cartilage grafts, and poor aesthetic results [7].

The ideal scaffold for ear reconstruction must have a high degree of biocompatibility and elicit little cellular or soft tissue reaction. It should be thin, lightweight and flexible, have a shape memory, and should promote tissue healing/re-epithelialization if it becomes exposed. The surface of the ideal scaffold should promote cellular and soft tissue adherence. Intuitively, it would seem that autologous cartilage is an ideal scaffold material, as it has all of the desired physical and biomechanical attributes, except for genetically defined shape [7],[8].

Brent from the USA and Nagata from Japan are two leading surgeons who have contributed a lot for the improvement and active reconstruction of microtic ears [9]. Their two techniques differ significantly regarding the complications. Brent's technique is a safe and step-by-step four-stage reconstruction. It consists of insertion of an autologous cartilaginous framework into a skin pocket, transposition of the lobule, construction of the tragus, and construction of a retroauricular sulcus [10].

Nagata's technique is only a two-stage technique consisting of two stages: the first stage includes transposition of the lobule of the auricle and reconstruction of the complete framework, including the tragus putting it into a skin pocket, and then the lobule is transposed. This stage corresponds to the first three stages of Brent's technique. The second stage entails constructing the retroauricular sulcus, during which the reconstructed ear is raised and an additional cartilaginous graft is used to increase the projection [11].

Song and Song [12] presented a modified single-stage total ear reconstruction procedure based on anatomic studies of the postauricular cutaneous circulation. The operation consisted of using a large, super thin, 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 was covered by a subcutaneous tissue flap and then skin graft. This method had been used to treat 15 cases of anotia, all with satisfactory results.

Park et al. [13] presented a review of their experience with 122 temporoparietal fascial flaps, which were used for coverage of fabricated autogenous cartilage frameworks in the total number of auricular reconstructions. Partial flap necrosis occurred in five cases, total necrosis in two of 14 microsurgically transplanted cases, cartilage infection in two cases, and paralysis of the frontal branch of the facial nerve in one case. There were no significant differences in 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).

Jiang et al. [14] introduced their two-stage technique for reconstruction of microtia in 68 patients. In the first stage, the 3D cartilage framework is fabricated. The skin flap and retroauricular fascial flap were elevated in the mastoid area. Then the framework was wrapped by the fascial flap from behind and covered by the skin flap from front. In the second stage, the crus, the tragus, and the conchal cavity were reconstructed. The reconstructed ears had a 3D configuration, and the cranioauricular angle of the reconstructed ears was similar to that of the contralateral ear.

According to Park [15], tissue expansion can net additional soft tissue for coverage, and the use of tissue expander has rapidly developed in recent years. Park introduced his experience using expanded skin in over 146 microtia reconstructions. Excellent results with few complications were documented. Because the auricle surface area is rugged and large, the non-hair-bearing skin in the mastoid area is not sufficient for the reconstruction. Therefore, expanding the non-hair-bearing skin of the mastoid area is a good way to overcome the problem of skin inadequacy [16].

In our study, we assessed reconstruction of the auricle in 22 patients with lobular-type microtia by Nagata classification (dysplasia grade 3 by Weerda classification) through comparing two techniques utilizing autogenous costal cartilage material. The first technique was a two-stage technique using temporalis fascia flap and skin graft, whereas the second one was a three-stage technique using tissue expander.

The surgical outcome was good to fair for majority of the patients in terms of size, texture, and shape of the ear according to doctor satisfaction, with no significant difference between the two techniques [Table 5] and [Table 7].

GBI score, which measures patient satisfaction according to the changes in life, was carried out for all patients and recorded. This score revealed no significant differences between both techniques in terms of total score, general subscale score, social support score, and physical health score [Table 6].

There was a significant difference between the two techniques regarding postoperative skin texture and the rate of development of postoperative complications in favor for group II using tissue expander. The encountered complications included sloughing of the skin, postoperative wound infection and donor-site morbidity [Table 8].


  Conclusion Top


The microtic ear can be satisfactorily reconstructed using autogenous costal cartilage graft either by two-stage technique (using temporalis fascia flap and skin graft) or three-stage technique (using tissue expander), with no significant difference between the two techniques in terms of doctor and patient satisfaction.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.Tollesfson TT. Advances in the treatment of microtia. Curr Opin Otolaryngol Head Neck Surg 2006; 14 :412-422.  Back to cited text no. 1
    
2. Osorno G. A 20-year experience with the Brent technique of auricular reconstruction: pearls and pitfalls. Plast Reconstr Surg 2007; 119 : 1447-1463.  Back to cited text no. 2
    
3. Zou Y-H, Zhuang H-X, Wang S-J, Xu F, Dai P, Han D-Y. Satisfactory surgical option for congenital microtia with defects of external auditory meatus (EAM) and middle ear. Acta Otolaryngol 2007; 127 : 705-710.  Back to cited text no. 3
    
4. Nagata SA. New method of total reconstruction of the auricle for microtia. Plast Reconstr Surg 1993; 92 :187.  Back to cited text no. 4
    
5. Weerda H. Classification of congenital deformities of the auricle. Facial Plast Surg 1988; 5 :385-388.  Back to cited text no. 5
    
6. Robinson K, Gatehouse S, Browning GG. Measuring patient benefit from otorhinolaryngological surgery and therapy. Ann Otol Rhinol Laryngol 1996; 105 :415-422.  Back to cited text no. 6
    
7. Tanzer RC. Microtia - a long-term follow-up of 44 reconstructed auricles. Plast Reconstr Surg 1978; 61 :161-166.  Back to cited text no. 7
    
8. Converse JM. Construction of the auricle in congenital microtia. Plast Reconstr Surg 1963; 32 :425-438.  Back to cited text no. 8
    
9. Shaw GM, Carmichael SL, Kaidarova Z, Harris JA. Epidemiologic characteristics of anotia and microtia in California, 1989-1997. Birth Defects Res 2004; 70 :472-475.  Back to cited text no. 9
    
10.Brent B. Technical advances in ear reconstruction with autogenous rib cartilage grafts: personal experience with 1200 cases. Pias Recostr Surg 1999; 104 :319-334.  Back to cited text no. 10
    
11.Brent B. Auricular repair with autogenous rib cartilage: two decades experience with 600 cases. Plast Reconstr Surg 1992; 90 :355-373.  Back to cited text no. 11
    
12.Song Y, Song Y. An improved one-stage total ear reconstruction procedure. Plast Reconstr Surg 1983; 71 :615-623.  Back to cited text no. 12
    
13.Park C, Lew DH, Yoo WM. An analysis of 123 temporoparietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction. Plast Reconstr Surg 1999; 104 :1295-1306.  Back to cited text no. 13
    
14.Jiang H, Pan B, Zhao Y, Lin L, Liu L, Zhuang H. A 2-stage ear reconstruction for microtia. Arch Facial Plast Surg 2011; 13 :162-166.  Back to cited text no. 14
    
15.Park C. Subfascial expansion and expanded two-flap method for microtia reconstruction. Plast Reconstr Surg 2000; 106 :1473-1487.  Back to cited text no. 15
    
16.Aguilar EF. Auricular reconstruction in congenital anomalies of the ear. Facial Plast Surg Clin North Am 2001; 9 :159-169.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]MenoufiaMedJ_2014_27_2_490_141735_t9.jpg



 

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