Correspondence: Krista L. Olson, MD, Bobby R. Alford Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine, One Baylor Plaza, NA-102, Houston, TX 77030 (firstname.lastname@example.org).
Objective To describe the novel use of a delayed chondrofascial flap to increase auricular projection in microtia reconstruction.
Methods Retrospective survey analysis. Ten consecutive children with unilateral microtia without other craniofacial abnormalities were followed up for a period ranging from 6 months to 5 years after microtia reconstruction was performed with the newly described delayed flap. Individual patient reconstructed auricular projection measurements were compared with contralateral (control) auricular projection values.
Results The auricular projection measurements taken at the superior helix and the lobule approximated those of the control side as confirmed by t test.
Conclusion The newly described delayed chondrofascial flap buttresses auricular projection in microtia repair to approximate the projection values of the normal side.
Total auricular reconstruction presents one of the greatest technical challenges for the facial reconstructive surgeon. In 1959, Tanzer1 established the basic surgical technique for microtia reconstruction using rib cartilage to fashion the auricular framework. Several authors have since described slight modifications of this technique to further refine the end result.2 More recently, Brent2 modified the Tanzer technique for microtia reconstruction in children and adolescents, producing outstanding results in the largest published series to date.
One area of microtia reconstruction that remains unsatisfactory to many surgeons is the inability to achieve sufficient auricular projection using the standard variations of the techniques previously mentioned. The goals of this article are to describe the novel use of a delayed chondrofascial flap in microtia reconstruction to increase auricular projection and to review our experience with this technique.
We reviewed the medical records in 10 consecutive unilateral pediatric microtia cases involving patients who underwent auricular reconstruction at our tertiary care academic institution from February 2001 through January 2004. Inclusion criteria were established to limit the cohort to patients with isolated microtia (without any associated craniofacial abnormalities) who had undergone all stages of reconstruction at our institution with a long-term follow-up minimum of 6 months. Informed consent for the procedure was obtained from the patients’ parents in all cases (all patients were younger than 18 years). All procedures in this case series were performed by one of us (T.F.K.) at the University of California at Irvine Hospital using the newly described delayed chondrofascial flap technique. Standard postoperative surface measurements and photographs were taken at long-term follow-up visits (range of follow-up, 6-36 months) after microtia reconstruction.
Surface measurements of both the normal and the reconstructed ears were taken with the head in the resting position using a standard measuring ruler and calipers. The following auricular dimensions were recorded: length, width, and projection. Length is measured from the most superior aspect of helix to the most inferior aspect of the lobule. Width is assessed from the root of the helix to the midhelical area correlating to the widest aspect of the auricle. Ear projection is measured from the most external point of the auricle to the conchomastoid skin at 3 points: superior helix, midhelix, and lobule (Figure 1).
Ear projection is measured from the most external aspect of the auricle to the conchomastoid skin at 3 points: A, superior helix; B, midhelix; and C, lobule.
Statistical analysis using a 2-sample, equal-variance, 2-tailed t test was performed to ascertain any significant differences between measurements of the normal side compared with the reconstructed auricle at 5 points: length, width, and projection at the superior helix, midhelix, and lobule.
A rectangular piece of cartilage with dimensions approximating 2 × 1.5 × 1.0 cm is carved from the rib cartilage harvested for ear framework fabrication (cartilaginous portions of ribs 6, 7, and 8). Through a postauricular incision, the pocket is created anteriorly for the insertion of the cartilaginous ear framework. Posterior to the incision, dissection is carried out to raise a flap of retroauricular fascia large enough to surround the rectangular piece of cartilage that will make up the chondrofascial flap (Figure 2 and Figure 3). The ear cartilaginous framework is inset in the anterior pocket. In the posterior aspect of the pocket, the rectangular piece of cartilage with preserved perichondrium is wrapped in the retroauricular fascia flap and secured using absorbable sutures (Figure 4 and Figure 5). The unit is now a composite chondrofascial flap. Hemostasis is obtained followed by the placement of a small suction drain attached to vacuum test tubes. A noncompressive dressing is applied over the petrolatum gauze molded around the ear cartilage framework. The chondrofascial flap is left in situ until the ear is elevated. At this time, the composite flap is advanced anteriorly into the postauricular sulcus to bolster the ear framework and to create better projection (Figure 6).
A rectangular piece of cartilage measuring 2 × 1.5 × 1.0 cm is carved from rib cartilage.
A retroauricular fascial flap of appropriate dimension is raised to surround the rectangular piece of cartilage that will make up the chondrofascial flap.
Drawing of the raised retroauricular fascial flap.
Drawing illustrating the fascia wrapping around the cartilage wedge.
The composite flap is advanced anteriorly into the postauricular sulcus to bolster the ear framework and to create better projection.
A total of 5 boys and 5 girls (age range, 5-9 years) underwent unilateral microtia reconstruction using the above-described technique from February 2001 through January 2004. The patients were seen in follow-up at short intervals after each surgical stage. Measurements (Table 1 and Table 2) and photographs (Figures 7, 8, 9, and 10) were taken at the long-term follow up visits (range of follow-up, 6-36 months). A direct comparison of the measurements indicated that the length and width of the reconstructed auricle approximated the dimensions of the normal ear within 0.7 and 2.0 mm, respectively. Complications encountered during this period included hypertrophic scar formation at the site of rib cartilage harvest in 2 patients. One patient had a small area of wound separation at the most cephalic extent of the ear cartilage graft after it was inset and before elevation of the auricle. There were no complications directly related to the use of the delayed chondrofascial flap.
Postoperative frontal view of 7-year-old patient with left-sided microtia who underwent reconstruction with a delayed chondrofascial flap.
Postoperative posterior view of same patient as in Figure 7 demonstrating increased auricular projection after the use of a delayed chondrofascial flap.
Right lateral view of same patient as in Figure 7.
Left lateral postoperative view of same patient as in Figure 7.
The t test analysis revealed no statistically significant difference in auricular height or width between the 2 groups (P = .66 and P = .28, respectively), and there was no statistical difference between the 2 groups in projection at the superior helix or lobule (P = .08 and P = .06, respectively). A statistical difference in projection at the midhelix between the 2 groups was detected using the 2-sample, equal-variance t test (P = .001).
Achieving adequate auricular projection is often believed to be the most challenging aspect of microtia reconstruction using the traditional methods. Several authors have proposed techniques to enhance postoperative projection using variations of fascial flaps as well as cartilage wedges.3-5 Brent3 described the placement of a cartilage wedge covered with a turnover “book flap” of occipitalis fascia to increase projection. This cartilage piece is harvested at the time of rib cartilage acquisition and preserved either in a subcutaneous pocket underneath the chest incision or in the scalp, just posterior to the main pocket where the completed ear framework is placed.
Nagata4 first reported the use of a semilunar piece of cartilage approximately 1 cm wide fixed to the posterior surface of the reconstructed ear and covered with a temporoparietal fascia flap to increase projection. It is believed that the semilunar shape allows adjustment and control of the degree of projection of the elevated ear, while the temporoparietal fascia flap strengthens the circulation of the posterior region of the ear and helps prevent necrosis and resorption of the cartilage. Ou et al5 modified the concept of the cartilage wedge enveloped by fascia using an anteriorly based retroauricular fascial turnover flap to cover a cartilage wedge. Their technique resulted in good projection along with the creation of a natural-appearing auriculocephalic sulcus and retroauricular hairline.
The technique we describe herein has several advantages compared with the above-mentioned methods. We use a delayed chondrofascial flap that preserves the integrity of the cartilage by wrapping it in a robust retroauricular fascial flap at the first reconstructive stage. At the time of auricle elevation, the cartilage wedge is easily advanced into position to achieve long-term projection that closely approximates the normal side. We have chosen a posterior incision for placement of our cartilage framework graft, which then allows easy elevation of a retroauricular fascial flap. Other authors often advocate an anterior incision, but we have found our results to be asthetically pleasing with good overall contour using the posterior incision.
Tolleth6 established certain guidelines for auricular dimensions that are followed in the process of auricular reconstruction. Most values for protrusion are measured at midauricle from the level of the upper end of the tragus to the mastoid skin. Some authors report measurements in degrees, while other have found a simple ruler to be an easier and more consistent way to establish protrusion.7 Using the ruler method, Tolleth6 estimated the average auricular protrusion in normal subjects to be between 1.5 and 2.0 cm.
To our knowledge, this study provides the first quantitative analysis of long-term microtia reconstruction values. Measurements at the midhelix for the reconstructed auricle using the delayed chondrofascial flap (mean, 1.2 cm) approximate the number described by Tolleth, although there was a statistical difference between the normal and reconstructed auricle values at this point (P = .001). However, projection measurements at the superior helix and lobule of the reconstructed auricle do not show a statistical difference when compared with the projection values obtained on the normal ear (P = .08 and P = .06, respectively). The projection values of the control side were below average in patients 2 and 5. The t test analysis of the data (excluding patients 2 and 5) revealed no significant difference in projection at the lobule between the control and reconstructed groups (P = .10).
Another advantage of the novel technique we have described is the preservation of the temporoparietal fascial layer that other authors have advocated as a cartilage covering.8 In our experience, the postauricular fascia has been found to have a robust blood supply. Although we know of no anatomical studies that have been performed specifically in patients with microtia to elucidate the details of blood supply in this region, we know from cadaveric studies that there is abundant collateral circulation from the occipital and postauricular arteries in this area.5 The preservation of the temporoparietal fascia is important for potential future use in a salvage secondary procedure.
In conclusion, we have described the novel use of a delayed chondrofascial flap to achieve auricular projection in micortia reconstruction that approximates normal projection values. This flap has been shown to produce reliable, sustained projection values that closely approximate those of the normal side as well as those of the population in general. Other advantages of the use of this flap include its ease of harvesting, without incurring any additional patient morbidity, and the preservation of the temporoparietal fascial layer.
Accepted for Publication: October 12, 2006.
Author Contributions:Study concept and design: Olson and Kelley. Acquisition of data: Olson. Analysis and interpretation of data: Olson. Drafting of the manuscript: Olson. Critical revision of the manuscript for important intellectual content: Olson and Kelley. Statistical analysis: Olson. Administrative, technical, and material support: Olson. Study supervision: Kelley and Crumley.
Financial Disclosure: None reported.
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