Auriculocephalic Angle Research Articles

One-Stage Nasal Reconstruction with Full-Thickness Composite Posterior Auricular Artery Perforator Free Flap

INTRODUCTION: Although there are diverse methods of reconstruction of large full thickness defects of the nasal region including zones II and III, these methods require the patients to undergo stepwise operations and thus these methods cannot be used when the patients cannot be followed up.1 In this respect, authors are to report a one-stage reconstruction method for nasal composite tissue defects using full-thickness composite posterior auricular artery perforator free flaps. METHODS: A 25-year-old male patient presented with a nasal composite tissue defect due to a human bite without amputee (Figure 1). He was a foreigner and could not be followed up after he would leave the country three months later. In this respect, the defective nasal region was reconstructed using a one stage full-thickness composite posterior auricular artery perforator flap. The wedge shaped defective region was around 2.5x2.5cm in size. The nasal lining defect was around 0.5x1cm in size. Unlike flaps that had been reported earlier, full-thickness composite tissues were harvested including the conchal skin to include both the conchal cartilage and the posterior auricular skin. The flap was inset so that the conchal skin would become the nasal lining, the conchal cartilage would become the alar cartilage and the posterior auricular skin would become the external skin. The recipient vessel was the lateral nasal artery and since no vein was connected, systemic heparinization was used to perform a salvation of the flap. The donor site was primarily closed.Figure 1: Initial presentation of the patient.RESULTS: The flap and the donor site were maintained well without any particular events postoperatively. Based on the CT taken at 20 days after the surgery, the conchal cartilage of the flap was identified as being maintained well. Silicone sheeting was performed from six weeks after the surgery and an appropriate nasal contour maintained in situ was identified at 10 months (Figure 2). The donor site showed a minor difference in the auriculocephalic angle except for slight narrowing of the intertragic notch.Figure 2: Postoperative 10-month view of the patient.CONCLUSION: The posterior auricular artery perforator flap using the full-thickness tissues of the ear can be used in one-stage reconstruction of nasal composite defects and showed satisfactory results. This is considered to be another good alternative for existing nasal region reconstruction methods that require multiple stages.

Auricular reconstruction for microtia with modified Nagata method

To investigate a method for total reconstruction of auricle. 90 patients (101 ears) with congenital microtia underwent two-stage operations for auricular reconstruction. The first stage involved fabrication and grafting of autologous costal cartilage, removing the remnant ear cartilage, embedding the framework into local flap of the mastoid region, transferring the remnant ear lobule flap to link to the inferior framework. The second stage was creating an auriculocephalic sulcus. The reconstruction was performed 4 - 12 months after the first surgery. Skin incision was made 5 mm lateral side of the posterior margin of the auricle. The ear framework carrying a thick ear fascia was separated from the side of the head, the frames of the costal cartilage banked at the first operation were harvested, shaved and transplanted to the posterior wall of the concha with sutures; adjust stand position and angle, so that made the ear shape, position, axis, close to the healthy ear, and auriculocephalic angle was slightly larger than the contralateral ear. Two random flap was designed with superior on the root of the helix and in the inferior-posterior direction of the inferior mastoid area, two flapes were elevated and transplanted to posterior auricular sulcus to cover the grafted cartilage. Skin graft was performed in the remaining raw surface. A total of 90 patients were operated, all of 101 constructed ears achieved satisfied or near satisfied shapes. Five cases of partial skin flap necrosis were caused by pedicle impairment. Exposure of cartilage framework happened in two cases. The auriculocephalic sulcus of four cases diminished after the second stage operation. Three month to two-year follow-up of 67 patients showed that the reconstructed ears were satisfied with the results, including good shapes and steady auriculocephalic angles. The method is a simple, safe and reliable method for total aural reconstruction.

Creation of auriculocephalic sulcus with two random skin flaps from mastoid area combined with skin graft

To investigate the method for creation of auriculocephalic sulcus. The reconstruction was performed 4-12 months after the first surgery. Skin incision was made 5mm posterior to the outer margin of the auricle. The ear framework was elevated with a thick fascia at the deep surface. The costal cartilage banked at the first operation was shaved and transplanted to the deep surface of the concha with sutures. The position and angle of the ear framework was adjusted to be familiar to the healthy ear. The auriculocephalic angle was slightly larger than that in the contralateral ear. Two flaps were designed at the upper and lower area of reconstructed ear and rotated to cover the cartilage. The wound at the donor site was closed with skin graft. A total of 72 patients were treated. All the flaps survived completely. 51 patients were followed up for 3-24 months with satisfactory results. The auriculocephalic sulcus maintained at about 20-30 degree. It is a simple, safe and reliable method to create a auriculocephalic sulcus with two random skin flaps from mastoid area combined with skin graft.

Molding the ears after anterior scoring and concha repositioning: a combined approach for protruding ear correction.

The goal of otoplasty for correction of prominent ears is normalization of shape and position of both pinnas with a certain symmetry. Recreating the antihelical fold and lowering the auriculocephalic angle are the basic processes for achieving a normal-looking ear. Various methods have been described to recreate the antihelical fold. In addition to anterior scoring or abrasion, many involve placement of permanent or absorbable sutures to reform the cartilage to proper shape to correct the deformity. In this study the use of a custom-made silicone mold was described after anterior scoring to recreate the antihelical fold, without using any suture material. Silicone molds provide good shaping of the antihelical fold, scapha, and helical rim while the tissue is healing. Fourteen patients underwent bilateral otoplasty for prominent ears in our clinic over a four-year period. The anthelical fold was created by anterior scoring and the concha-mastoid angle lowered and sutured. After completing the surgical procedure for both ears, custom-made silicone molds were worn by the patient for the first two weeks to maintain proper position. The third week, the patient wore the mold half a day. A head dressing was used for two days and the ears were subsequently supported using a headband. Follow-up ranged from fourteen months to four years. One patient developed a postoperative hematoma in one ear that resorbed spontaneously. Patient satisfaction with the procedure was generally high. Using a shape mold after a combination of anterior scoring and concha repositioning gives predictable results with a natural-looking ear.

Minor physical anomalies in schizophrenia: is age a confounding factor?

Minor physical anomalies (MPAs) occur more frequently in a range of developmental disorders. They are also more frequent in schizophrenia supporting a neurodevelopmental aetiology of the illness. Contemporary MPA scales are yet to be validated for the effects of age. It is hypothesised that the effects of ageing may be confounding when these scales are applied to an elderly population. The distribution of MPAs in a normal elderly population was compared with younger subjects. Fifty subjects over the age of 60, and 50 subjects below the age of 60, with no known major mental illness, were evaluated. MPAs were assessed using a modified Lane scale [Psychol. Med. 27 (1997) 1155]. Elderly subjects showed an excess of absent trichions due to alopecia ( p=0.004) short and broad palates ( p=0.01) and greater ear protrusion ( p=0.004) relative to young subjects. The differences reported are probably due to hair loss, edentulousness and growth of the auriculocephalic angle with age. These findings question the validity of studies of MPAs in schizophrenia that do not control for age.

Microtia: technique for external ear reconstruction with autologous rib cartilage

Various methods for treatment of classic microtia are known. Beside a prosthesis, the most common way of auricle reconstruction is the use of autogenous rib cartilage; a process that requires two to three operations. In the first operation, rib cartilage is harvested from the 6th to the 9th rib. The base of the framework is the 6th and 7th rib cartilage which is taken under preservation of the synchondrosis. To mimic a 3-dimensional structure, the triangular fossa and scapha are carved into the groundplate and the 8th rib is fixed as a helical rim. After optimising the framework, it is placed in a subcutaneous pocket on the mastoid plane. In a second operation, approximately three months later, the auriculocephalic angle is reconstructed with a cartilage wedge, which is covered by a temporalis fascia flap and split skin-graft from the hairbearing skull. Commonly, a third operation is needed for minor refinements. Currently, autogenous rib cartilage is the ideal material available for ear reconstruction resulting in an excellent cosmetical outcome, although harvesting of the cartilage causes a specific donor-site morbidity. Operations improving the hearing ability by building up the external hearing channel and middle ear are mainly done in cases of bilateral microtia. Ear reconstruction with autogenous rib cartilage produces a replicable aesthetic result. The patients should be at least eight years old.

Elevation of a constructed auricle using the anteriorly based mastoid fascial flap

Two-stage methods for reconstruction of congenital microtia have been widely utilised. To obtain a desirable auriculocephalic angle and provide a nutrient support to the constructed auricle, elevation of reconstructed ears using a costal cartilage graft, the anteriorly based mastoid fascial flap transfer and a skin graft was performed as the second operation for nine microtia patients. In this procedure, the mastoid fascial flap was used instead of the temporoparietal fascial flap. Following the elevation of the reconstructed ear the anteriorly based mastoid fascial flap was harvested. A carved costal cartilage was grafted at the posterior wall of the concha and covered with the mastoid fascial flap, followed by a full-thickness skin graft from the inguinal region. The skin grafts took well and the appropriate auriculocephalic angle was preserved in all cases. This method was easy to perform and did not leave any scar in the temporal hair-bearing area.

Microtia repair.

Management of microtia can be one of the most rewarding yet humbling challenges faced by the reconstructive surgeon. The preferred method of total auricular reconstruction is with autologous cartilage and skin, based on modifications of the methods of Tanzer and Brent. Our goals in auricular reconstruction of microtia are: (1) a satisfied patient; (2) proper positioning; and (3) a pleasing size and contour. The reconstructive process in classic microtia reconstruction can be divided into four stages. The first stage is the creation and placement of the underlying framework derived from the autologous rib cartilage of the sixth to eighth ribs. The second stage is rotation of the lobule from the microtia remnant into position inferiorly on the helical rim. The third stage is elevation by creation of an auriculocephalic angle with a skin graft. The final stage is formation of the tragus from a composite graft from the opposite ear. Atypical microtia presents distinct challenges to the reconstructive surgeon. Complete framework insertion may not be necessary with the presence of some recognizable structure. Other circumstances arise that make each reconstruction unique, such as low-lying hairline or skin shortage. The extreme situations of skin shortage will benefit from the use of a temporoparietal fascia flap. However, adherence to the well-established principles of total auricular reconstruction will lead to satisfaction of the patient, the patient's family, and the surgeon.

A Single-Stage Two-Flap Method of Total Ear Reconstruction

A single-stage two-flap method of total ear reconstruction in congenital microtia is reported. This method was derived from the one-stage reconstruction described by Song and Song. Two flaps defined by vascular basis were elevated on the mastoid area: the superficial skin flap supplied mainly by subcutaneous pedicled arteriole perforators from the posterior auricular artery and the deeper axial-pattern fascial flap including the posterior auricular artery itself. The ear framework, exaggeratedly carved using autologous rib cartilage, could be inserted easily between the two flaps, simultaneously producing the auriculocephalic angle and the conchal wall. Intraoperative expansion of the skin flap and postoperative external ear molding also were performed to create aesthetically pleasing ears.