Pursuing Mirror Image Reconstruction in Unilateral Microtia: Customizing Auricular Framework by Application of Three-Dimensional Imaging and Three-Dimensional Printing.

Abstract

Sir: Recently, Hsin-Yu Chen and colleagues published a study entitled “Pursuing Mirror Image Reconstruction in Unilateral Microtia: Customizing Auricular Framework by Application of Three-Dimensional Imaging and Three-Dimensional Printing,” highlighting treatment of microtia using three-dimensional imaging and three-dimensional printing aiming to recreate mirror image reconstruction of the auricle.1 We congratulate the authors for such a well-designed and well-executed study. Although we commend the idea and desire to create an identical auricular framework in patients affected by microtia, and the use of modern technology to treat this patient population, a few considerations are warranted. As plastic surgeons, we strive to restore symmetry as accurately as possible. Although such symmetry is paramount in areas of the body that are immediately seen together at conversational distance (e.g., eye position, nose, lips), human ears are almost never visible or observed simultaneously. The detail of a single ear at a time is visible mostly in the lateral or three-quarters view. Simultaneously, the contralateral ear is “eclipsed” in the nonvisible part of the face. For such reason, rather than recreating a perfectly matching auricle, the attention should be focused on reconstructing an auricle with the utmost detail to create a reconstruction that mostly resembles a normal human ear. This is true from a cartilaginous framework standpoint and equally for the soft-tissue coverage of the framework itself. If possible, avoidance of skin grafts on the anterolateral aspect of the construct, which may lead to contracture, is important to maintain the original detail obtained during the reconstruction. Autologous reconstruction in this regard shows superior results. Although resorption of the cartilaginous framework was mentioned by the authors as one of the drawbacks of the autologous reconstruction technique, resorption is, in fact, not significant when proper technique is used. Although we agree that the use of the Medpor (Stryker, Kalamazoo, Mich.) implant may be appropriate in selected cases (e.g., lack of appropriate donor sites, patient choice, inability to travel to a surgeon able to perform the autologous reconstruction appropriately), the complications in these patients can be significant.2,3 The challenges in performing the autologous procedure,4 which the authors themselves recognize as the optimal procedure, and its steep learning curve should not deter plastic surgeons from mastering autologous reconstruction. Finally, although this new technology is exciting and innovative, is the technology available everywhere in the world, especially in those countries with the highest incidence of microtia? Many of these patients live in regions with limited access to medical care and scarce resources, and travel to countries where this technology may be available in the future is unlikely. Moreover, what is the cost of such technologies? What would the learning curve for the physicians be? We agree with Chen et al. that new technologies that allow low-cost, safe, high-quality ear reconstruction would be welcome, with the main focus of improving the overall auricular framework definition. DISCLOSURE Dr. Leto Barone is co-founder and co-owner of ReconstratA, a medical device company that focuses on engineering solutions for plastic and reconstructive surgery, and the co-inventor of AuryzoN, a device designed to aid microtia and complex nose reconstructions. Dr. Redett has no financial disclosures related to the topic of this communication. Angelo A. Leto Barone, M.D.Richard J. Redett, M.D.Department of Plastic and Reconstructive SurgeryThe Johns Hopkins School of MedicineBaltimore, Md.