Autogenous Cartilage Framework Research Articles

Microtia Ear Reconstruction with Patient-Specific 3D Models-A Segmentation Protocol.

(1) Background: In recent years, three-dimensional (3D) templates have replaced traditional two-dimensional (2D) templates as visual guides during intra-operative carving of the autogenous cartilage framework in microtia reconstruction. This study aims to introduce a protocol of the fabrication of patient-specific, 3D printed and sterilizable auricular models for autogenous auricular reconstruction. (2) Methods: The patient’s unaffected ear was captured with a high-resolution surface 3D scan (Artec Eva) and post-processed in order to obtain a clean surface model (STL format). In the next step, the ear was digitally mirrored, segmented and separated into its component auricle parts for reconstruction. It was disassembled into helix, antihelix, tragus and base and a physical model was 3D printed for each part. Following this segmentation, the cartilage was carved in the operating room, based on the models. (3) Results: This segmentation technique facilitates the modeling and carving of the scaffold, with adequate height, depth, width and thickness. This reduces both the surgical time and the amount of costal cartilage used. (4) Conclusions: This segmentation technique uses surface scanning and 3D printing to produce sterilizable and patient-specific 3D templates.

Management Strategy of Local Subcutaneous Effusion After Auricle Reconstruction.

Microtia is a severe congenital malformation of the external ear, and auricular reconstruction is still a challenge for plastic surgeons because of the complicated procedures and rare conditions. This study aimed to describe the location of subcutaneous effusion after auricular reconstruction and explore the clinical efficacy of the indwelling needle puncture drainage method in the treatment of local subcutaneous effusion. From January 2017 to December 2019, 1240 patients (1296 affected sides) who underwent auricular reconstruction using autogenous cartilage framework in the Plastic Surgery Hospital of Chinese Academy of Medical Science and Peking Union Medical College were selected. The local subcutaneous effusion occurred within 5 days after the drainage tube was removed, and the indwelling needle was used for puncture and drainage in the postoperative treatment. A total of 55 patients had subcutaneous effusion after the operation, including 24 cases with Nagata's method and 31 cases with the expanded single-flap method. One patient showed no obvious reduction after puncture and drainage by indwelling needle and improved after the secondary operation. Two patients had slight cartilage absorption. The remaining patients had good results. The method of the indwelling needle for puncture and drainage is easy to operate. The problem of local subcutaneous effusion after auricular reconstruction can be solved and good efficacy can be obtained.

Nasal Reconstruction and Repair of Secondary Nasal Deformities Following Treatment of Nasal Hemangiomas

Secondary nasal deformities and retardation of development due to treatment of nasal hemangioma during infancy are a challenge when it comes to nasal reconstruction. In order to evaluate nasal repair and reconstruction in these patients, the authors compared the ease and outcomes of using expanded forehead, nasolabial sulcus, and medial upper arm tube flaps. According to the deformities and patients' wishes, flaps were selected; using autogeneic rib cartilage, auricle cartilage, or silica gel as a scaffold or without framework; the inner lining were made by the residual scar tissue or the distal end of transferred flap. The esthetical and functional scores were recorded by the Nasal Appearance and Function Evaluation Questionnaire score to evaluate the effectiveness of the methods. From January 2010 to December 2015, 34 patients were included. Postoperative follow-up went for 12 to 36 months. The expanded forehead flap was used in 28 patients, the nasolabial sulcus flap in 5 patients, and the medial upper arm tube flap in 1 patient. Regarding framework, 20 patients used rib cartilage, 8 patients used auricle cartilage, 1 patient used silicone, and 5 patients did not use any framework. All patients reported the increasing nasal appearance and function evaluation. Repair of secondary nasal defects following treatment of hemangiomas in infants and young children using an expanded frontal flap and autogenous cartilage framework is a reliable method with great long-term esthetic results. The nasolabial sulcus flap is a relatively simple method, especially for patients with a unilateral nasal alar defect. Supporting structure is needed and appropriate overcorrection is necessary.

Analysis of clinical diagnosis and treatment in patients with microtia in Klippel-Feil syndrome

To analyze the clinical features and diagnostic and therapeutic procedure of microtia in Klippel-Feil syndrome(KFS),and to summarize the experiences on diagnosis and treatment of this kind of rare disease to avoid misdiagnosing. . Between May 2014 and July 2015,six patients with microtia were diagnosed with suspected cervical vertebral malformation through physical examination and X-ray. Then they underwent additional examinations to evaluate the degree of deformities and relative risks:pure tone test, chest CT,cervical spine CT,temporal CT, echocardiography and ultrasonic on kidney and ureters. Ear reconstruction was performed with soft tissue skin expander and autogenous rib cartilage framework. The six patients were diagnosed as KFS with microtia, which had different degree of cervical fusion and thoracic vertebral fusion. Some of them had rib deformity, scoliosis, congenital renal malformation and so on. Of 6 patients, scar formation occurred in 1 case after ear reconstruction, whose new ears had good position and appearance at 1 month after stage Ⅱ. After operation,6 cases were followed up for 8-20 months (median,12 months),none of them had nerve injury. Five cases had completed the third stage. All of them were well-healed after one month. Three cases were followed up for 3-11 months, the reconstructed ears had a three-dimensional configuration, and the cranioauricular angle of the reconstructed ears were similar to the opposite ears The primary step of comprehensive therapy in microtia with KFS is to diagnose definitely. Enhancing perioperative management can reduce surgery-related risks. It is ought to pay attention to nerve injury in a long-term follow-up.

Osseointegrated Implants: An Alternative Approach in Patients with Bilateral Auricular Defects due to Chemical Assault.

Acid attacks committed as crimes of passion are unfortunately becoming far from infrequent occurrence. The injuries sustained in such attacks mainly involve the face and trunk, with the acid causing cutaneous and subcutaneous tissue burns that can result in permanent scarring, loss of the nose or external ear, and severe visual impairment. Different surgical solutions have been proposed for reconstruction of the auricle following loss of the ear through traumatic injury or cancer or in patients with congenital defects: surgical reconstruction may involve the insertion of an autogenous rib cartilage framework or the use of a porous polymer material inserted into an expanded postauricular flap. Reconstruction with rib cartilage has given good results but requires more than one surgical step and may be associated with adverse events involving both the donor site and the recipient site, while rejections of polymeric prostheses have been reported following their insertion into expanded postauricular flaps. The use of a titanium dowel-retained silicone prosthesis, in which the dowel is anchored to the temporal bone, is a surgical possibility, indicated particularly in cases of pinna resection due to tumour or auricular scarring following traumatic injury.

Bone-Anchored Titanium Implants in Patients with Auricular Defects: Three Years and 27 Patients' Experience.

Different surgical solutions have been proposed for reconstruction of the auricle following loss of the pinna through traumatic injury or neoplastic disease or in patients with congenital defects. Surgical treatment may involve the insertion of an autogenous rib cartilage framework or the use of a porous polymer material inserted into an expanded postauricular flap. Reconstruction with rib cartilage has yielded good results but requires more than one surgical step, and adverse events can occur both at the donor and at the acceptor site; cases of prosthesis rejection have also been described following application of the polymeric prosthesis. The use of a titanium, dowel-retained silicone prosthetic pinna, fixed to the temporal bone, has recently been proposed. This useful surgical approach is indicated particularly after resection of the pinna caused by neoplastic disease or in traumatic auricular injury. Osseointegrated titanium implants used in 27 patients in this study provided them with a safe, reliable, adhesive-free method of anchoring the auricular prostheses. The prostheses allowed recovery of normal physical appearance and all the patients reported that they were completely satisfied with the outcome of the surgical reconstruction. No surgical complications, implant failures, or prosthetic failures were encountered over six months to three years.

Application of mastoid flap for correction of moderate or severe cup ear

Objective To propose a practical method for moderate-to-server cup-ear correction.Methods Auricular reconstruction was performed in a manner of two-stage approach with mastoid flap and costal cartilage support.In the first stage,the autogenous costal cartilage framework was inserted under the retroauricular mastoid skin flap.The corrected ear was raised in the second operation and wound was closed with grafting skin.Results Satisfaction of appearance was achieved for totally 18 cases except one case of partly necrosis of cartilage.They were followed-up for 3-26 months.Conclusions This integrative two-stage approach of mastoid flap combining three dimensional costal cartilage is safe and effctive for moderate to severe cup-ear correction,which brings about good appearances and symmetry.The complications are in control. Key words: Cup ear; Skin flap; Deformity

Correction of secondary nasal deformity of cleft lip with autogenous costal cartilage framework

To investigate the correction of secondary nasal deformity of cleft lip with autogenous costal cartilage framework. 237 cases with secondary nasal deformity of unilateral cleft lip were treated. The rib cartilage was harvested through a mini-invasive incision, and was fabricated as a C-shaped framework, as well as some cartilage fragments. Through transcolumella incision, the C-shaped framework was implanted to support the depressed alar and the cartilage fragments were used to augment the nasal base. Satisfactory cosmetic and functional results were achieved in all the patients with primary healing. 93 patients were followed up one year after operation with good cosmetic results. Autogenous costal cartilage framework can be used for the correction of secondary nasal deformity of cleft lip with satisfactory results.

Current opinion on auricular reconstruction

To review the current practice in the field of auricular reconstruction and to highlight the recent advances reported in the medical literature. The majority of surgeons who perform auricular reconstruction continue to employ the well-established techniques developed by Brent and Nagata. Surgery takes between two and four stages, with the initial stage being construction of a framework of autogenous rib cartilage which is implanted into a subcutaneous pocket. Several modifications of these techniques have been reported. More recently, synthetic frameworks have been employed instead of autogenous rib cartilage. For this procedure, the implant is generally covered with a temporoparietal flap and a skin graft at the first stage of surgery. Tissue engineering is a rapidly developing field, and there have been several articles related to the field of auricular reconstruction. These show great potential to offer a solution to the challenge associated with construction of a viable autogenous cartilage framework, whilst avoiding donor-site morbidity. This article gives an overview of the current practice in the field of auricular reconstruction and summarizes the recent surgical developments and relevant tissue engineering research.

Reconstruction of Microtia

The reconstruction of microtia continues to represent one of the more challenging plastic surgery procedures. The limitations of the reconstruction are partly inherent in the soft-tissue deficiencies present in increasing degrees from large conchal remnant microtia, to lobular microtia, to the displaced remnant in auricular dystopia, and partly because of the high level of technical expertise required. After a brief review of the history of ear reconstruction in general and microtia specifically, issues related to the transition in the popularity from techniques involving three or more stages (Tanzer and Brent) to the current popularity of two-stage procedures (Nagata, Firmin, and Park) are discussed in detail. Each of the popular procedures is viewed in relation to timing of the reconstruction, procedure planning, and how both the soft tissues and framework construction are handled, in each of the stages. The most significant differences include whether the autogenous cartilage framework is constructed with or without the tragal construct (for the lobular-type microtia), whether or not the lobule is rotated in the first-stage reconstruction, whether an additional cartilage block is placed behind the framework for added ear projection, and how that added block is covered (choice of fascia flap and skin graft). Each of the techniques has to be varied in reconstruction of auricular dystopia in light of the associated skeletal and soft-tissue hypoplasia. In this article, the author demonstrates that although there may be significant advantages to the two-stage reconstructions of Nagata and Firmin, some may feel that the larger amount of cartilage harvested, the later optimal age for beginning the reconstruction, the additional scalp scars engendered by using the temporoparietal fascia flap in the second-stage elevation of the framework, and even the exchange of lobule tissue (and ability to later pierce ears) to obtain better coverage of the concha and tragus are unacceptable. Having gained experience with each of the varied approaches and having modified them when unusual variations in deformities have required it, the author discusses his current preferences. Clearly, this author feels that there may be significant advantages to delaying the reconstruction to age 10 years or older, yet experience gained over the past 25 years would seem to indicate that as in all other aspects of plastic and reconstructive surgery one must never be wed to a single approach, and experience and flexibility are essential in obtaining the optimal outcome in all variations of the deformity.

Fabrication and application of three-dimensional autogenous cartilage framework in auricular reconstruction

To explore the fabrication and application of three-dimensional autogenous cartilage framework in auricular reconstruction. The process of fabrication of three-dimensional cartilage framework consisted of cartilage harvesting, carving and assembling the cartilage. The rib cartilage was harvested separately. The three-dimensional framework was composed of three main parts:the helix, the base and the pad, at different layer. The framework was fabricated according to the development of rib cartilage and contour and height of the reconstructed ear. From January 1992 to December 2006, 5,248 patients of microtia were treated with 6,252 autogenous cartilage frameworks. The three-dimensional framework is easily manipulated. The reconstructed ears look natural and had an erect contour. This method can effectively use the cartilage.

The anatomy and application of the postauricular fascia flap in auricular reconstruction for congenital microtia

The various layers of the scalp are widely used in reconstructive procedures. The technique used for soft tissue coverage seems to influence the framework extrusion rate in auricular reconstruction. We have investigated the role of the postauricular fascial flap in providing ample, thin neurovascular cover to facilitate ear reconstruction in congenital microtia. Following postauricular cutaneous tissue expansion, the postauricular neurovascular fascia flap was raised to partially cover the projected three-dimensional autogenous cartilage framework. A suction drain was placed in the pocket to allow the skin to coapt to the framework and a split-thickness skin graft was applied to complete coverage. At final assessment, the aesthetic results were analysed subjectively. Four hundred and thirty-eight ears underwent total ear reconstruction in 428 patients using the postauricular fascial flap technique. None of the reconstructions failed, and all patients were satisfied with the results. The use of a postauricular fascial flap and skin graft enhances safety and provides better vascularisation of the underlying cartilage.

Use of an Expanded Temporoparietal Fascial Flap Technique for Total Auricular Reconstruction

The authors propose an expanded technique of the temporoparietal facial flap of sufficient size to provide complete coverage in a single-stage procedure for the projected three-dimensional autogenous cartilage framework, including the tragus or lobule.A temporoparietal fascial flap measuring 9 x 9 cm was prepared and wrapped around an expander. The expander was gradually infused with saline solution. Approximately 6 months after the first operation, a projected three-dimensional auricular framework was covered by the expanded temporoparietal fascial flap. Nine patients underwent total ear reconstruction using the expanded temporoparietal fascial flap technique. Of these, two cases were anotia, five were failed reconstructed microtia, and two were posttraumatic absence of ear.A final aesthetic assessment of the results was analyzed subjectively. Three cases showed excellent results, four cases showed good results, one case showed a fair result, and one case showed a poor result.This expansion technique is indicated in reconstruction of anotia patients who require longer and wider fascial flaps and in auricular reconstruction patients undergoing microvascular free fascial flap transfer for lessening postoperative vascular obstruction, when microvascular anastomosis is performed on the retroauricular region. The technique is also indicated in salvage auricular reconstruction for patients with an unusual vascular pattern on the temporoparietal fascial flap, or for patients showing a vascular insufficiency of the flap's distal portion after flap elevation.

Use of an Expanded Temporoparietal Fascial Flap Technique for Total Auricular Reconstruction

The authors propose an expanded technique of the temporoparietal facial flap of sufficient size to provide complete coverage in a single-stage procedure for the projected three-dimensional autogenous cartilage framework, including the tragus or lobule. A temporoparietal fascial flap measuring 9 x 9 cm was prepared and wrapped around an expander. The expander was gradually infused with saline solution. Approximately 6 months after the first operation, a projected three-dimensional auricular framework was covered by the expanded temporoparietal fascial flap. Nine patients underwent total ear reconstruction using the expanded temporoparietal fascial flap technique. Of these, two cases were anotia, five were failed reconstructed microtia, and two were posttraumatic absence of ear. A final aesthetic assessment of the results was analyzed subjectively. Three cases showed excellent results, four cases showed good results, one case showed a fair result, and one case showed a poor result. This expansion technique is indicated in reconstruction of anotia patients who require longer and wider fascial flaps and in auricular reconstruction patients undergoing microvascular free fascial flap transfer for lessening postoperative vascular obstruction, when microvascular anastomosis is performed on the retroauricular region. The technique is also indicated in salvage auricular reconstruction for patients with an unusual vascular pattern on the temporoparietal fascial flap, or for patients showing a vascular insufficiency of the flap's distal portion after flap elevation.

A New Device for Creating and Positioning an Autogenous Cartilage Framework during Microtia Reconstruction

This paper describes the fabrication and use of a three-dimensional appliance, known as the microtia surgical positioner, to more accurately position and better sculpt the autogenous rib cartilage graft during microtia reconstruction. The authors introduce a new device design and surgical application. An impression and plaster cast were made from the patient's auricular defect. On this cast, the artist then created a wax baseplate and an esthetically pleasing wax sculpture of an ideal ear similar to the patient's normal contralateral ear. The surface contour of the patient's auricular defect locked the wax baseplate into a stable position, the ear sculpture was then properly positioned on the baseplate, and the two pieces were joined. The artist made a silicone mold of the wax prototype and casted the clear acrylic resin surgical positioner using that mold. Finally, an opening along the helical portion was drilled in the positioner. Intraoperatively, the positioner locked into the surface contour of the patient's auricular defect, thus assuring accurate positioning of the cartilage graft. The surgeon marked the correct helix position with the device's helix and helical port and used the positioner as a model to guide the carving and assembly of the cartilage framework. Our group successfully created and used a microtia surgical positioner. The positioner guided accurate superior-inferior, anterior-posterior, and rotational placement of the helical portion of the cartilage graft. The surgical positioner also significantly contributed to detailed sculpting of the graft. : Medical artists and surgeons may cooperate to fabricate and use a surgical positioner to guide accurate placement of the cartilage framework and assist with sculpting of the graft for total auricular reconstruction.

An analysis of 123 temporoparietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction.

This article presents an updated review of our experience with 122 temporoparietal fascial flaps, which were used for coverage of fabricated autogenous cartilage frameworks in total auricular reconstructions. Our indications for use of the temporoparietal fascial flap are presented. Partial flap necrosis occurred in 5 cases, total necrosis in 2 of 14 microsurgically transplanted cases, cartilage infection in 2 cases, and paralysis of the frontal branch of facial nerve in 1 case. Prospective observations of vascular anatomy were carried out in the last 93 temporoparietal fascial flaps during flap elevations. Only 59 flaps (63.4 percent) showed a typical pattern, distributed mainly by the superficial temporal artery and vein. Others (36.6 percent) were distributed mainly by various combinations of the posterior auricular artery or vein, occipital artery or vein, diploic vein, and the superficial temporal artery or vein. At the upper margin of the imaginary reconstructed auricle, the mean diameters of the artery and vein were 1.7 mm and 2.2 mm, respectively. There were no significant differences of 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). We are presenting our technical evolution in using the temporoparietal fascial flap for total auricular reconstruction with the goal of reducing surgical complications and improving aesthetic results.

Growth Potential of Autogenous Cartilage Grafts in Expanded Skin: An Experimental Study in Rabbits

The effect of tissue expansion on the growth potential of autogenous cartilage grafts was studied in 10-day-old New Zealand white rabbits. The rabbits were divided into two groups: In Group 1 (n = 12) after 2 weeks of tissue expansion by using a 10-ml tissue expander, a cranially based 4 x 4-cm dorsal skin flap was raised and a 1 x 1-cm autogenous cartilage graft from the midportion of the left ear was transplanted beneath the flap in each rabbit. In Group 2 (n = 12) elevation of dorsal skin flaps and transplantation of the grafts were performed in the same way but without a previous tissue expansion. The grafts were removed at 30 and 60 days after transplantation in both groups, for histological examination and measurement of the dimensional changes to determine the growth rate. In both groups, histological examination revealed characteristic findings for cartilage growth, however, Group 1 (expansion) demonstrated a statistically significant increase in the growth of cartilage grafts when compared with Group 2 (control) (p = 0.0001). The results of this study indicate, from the standpoint of acceptance and growth potential of autogenous cartilage framework, that there is no drawback to using this tissue expansion technique for reconstruction of the ear in childhood.

Auricular Repair with Autogenous Rib Cartilage Grafts

The purpose of this paper is twofold: to present a sound approach to auricular construction using methods that have evolved through two decades of my personal experience with 600 cases and to discuss pertinent information I have gleaned from a questionnaire sent to my operated patients. This series comprises 546 completed ears in 500 microtia patients (46 bilateral) and 75 completed ears in acquired deformities. Follow-up ranges from 1 to 17 years. Major complications such as infection, hematoma, or skin loss with cartilage exposure occurred in only 1.6 percent of cases and were limited to the perioperative period of 12 days. None have occurred in the last 9 years (481 frameworks). This paper describes the evolution and rationale for my current management of total ear repair and covers preoperative planning, how to fabricate the rib cartilage framework, how to modify the framework for specific deformities, and how to cover the framework, i.e., how to assess and use local skin and vestiges or when to supplement the coverage by recruiting fascial flaps or using tissue expansion. When considering fascial flaps, patient selection was found to be particularly important because of long-term effects on the donor scalp; expansion was found to be most useful intraoperatively. This paper also covers how to manage the hairline, how to stage the surgery, when to combine procedures, and how to manage bilateral microtia in a team approach. The survey revealed that autogenous cartilage frameworks grow, are durable, retain their detail over the years, and withstand trauma well. More than 40 severe traumas occurred in surgically constructed ears, and all healed without incident. Ears constructed in young patients generally grew to keep pace with the opposite normal side; 41.6 percent actually overgrew by several millimeters. Emotional and psychological benefits were universal, and patient satisfaction was high. Among patients who were classified as "severely affected" by the original deformity, 100 percent were pleased with the result. When considered "moderately disturbed" by the microtic defect and operated on by age 14, 95.5 percent of patients were satisfied with the surgical repair; 83.3 percent of adolescents between the ages of 15 and 20 who did not consider themselves "severely affected" by the deformity were pleased with the outcome, and the rest were "undecided."

Overview of Experience of Tanzer’s Group with Microtia*

A review of our patients since Dr. Tanzer's retirement in 1970 shows good and lasting results after reconstruction of microtia using autogenous cartilage frameworks and staged procedures. There has been no evidence of shrinkage or distortion of the cartilage in any of our own patients, and the majority of them are pleased with their ears. With a cooperative and well-motivated patient and surgeons who are skilled and experienced in the procedure, ears can be made with a relatively normal size, shape, and position to match closely the other side. We continue to feel strongly that autogenous cartilage is the safest and best material to use for the ear framework. At some time in the future the body may be taught to accept homografts as if they were its own tissue, and allografts may be available that are tolerated as well as living tissue. Until then we will rely on autogenous tissue and our present techniques, which have produced long-lasting good results. Altogether the combined experience with ear reconstruction of Tanzer's group at the Dartmouth-Hitchcock Medical Center spans more than 30 years.

Advances in Reconstruction of Major Congenital and Acquired Auricular Defects

At the meeting of the American Academy of Otolaryngology–Head and Neck Surgery in Washington, DC, Bruce S. Bauer, MD, and collaborators, Medical College of Wisconsin, Milwaukee, recently reported 123 auricular reconstructions, including 81 microtias and 42 major acquired defects. Their report emphasized a three-stage reconstruction, beginning at age 5 years. These stages include (1) the placement of autogenous cartilage framework, harvested from rib cartilage; (2) lobule rotation and deepening of the concha; and (3) elevation of the helical margin with additional modification. The use of tissue expanders and vascularized temporoparietal fascia flaps have also proved helpful in auricular reconstruction. The authors stated that with these modifications, consistent results can be obtained in auricular reconstruction.